MEDICARE: MICHELLE KRISTINE LASTOVICA PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	19860	NC

General Provider Information

NPI Number	:	1679841100
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE KRISTINE LASTOVICA PHARMD

Provider Business Mailing Address
First Line	:	1400 MEDFIELD RD
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27607-4722
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3201 EDWARDS MILL RD STE 123
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27612-5370
Country	:	US
Telephone Number	:	919-781-2314
Fax Number	:	919-786-1326

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/12/2011
Last Update Date	:	12/12/2011

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